8th April 2020
It is just over two months since the first confirmed cases of the novel coronavirus COVID-19 were reported in the UK and the total number of cases has now risen to more than 51,000 in the UK and are approaching 1.32 million worldwide. In the UK, the total number of deaths from coronavirus is now doubling every 5 days, with strong evidence that we are following a similar trajectory to Italy, with Italy approximately two weeks ahead of the evolving crisis in the UK. While the daily number of deaths from confirmed coronavirus has yet to peak in most countries, in those who have adopted very strong countermeasures such as China and South Korea, the number of daily deaths has declined due to early testing and tracing of recent contacts for those who are COVID-19-positive.
Protecting the NHS
The current UK government’s position has been to contain the spread of coronavirus by a variety of measures including social distancing, working from home, closure of leisure facilities and a ban on social gatherings and non-essential travel. The ambition to reduce the peak number of daily coronavirus patients so that NHS resources are not overwhelmed appears to have been well understood and accepted by the public. In fact, there are some early signs that this may be starting to have an effect, with small decreased in the daily number of deaths during recent days. Further data over the coming days will help predict when the peak number of new daily cases has been reached, and how the next phase of the government strategy will take shape.
NHS-private sector agreements put patients with time-critical conditions at risk
As part of the overall strategy, the NHS reached an agreement with private UK healthcare providers in March 2020 to increase access to the number of beds and intensive care facilities by requisitioning of networks of private hospitals. Very few private hospitals have intensive care beds however, and intensivists raised concerns at the time that this approach would not be successful, as many private beds would require a significant upgrade to make them suitable for intensive care treatment. While the collaboration between the NHS and private sector was well received in the media to help tackle the coronavirus pandemic, I would have preferred public/private partnership that established a network of private hospitals that could continue to provide diagnostics and treatment for many different time critical diseases and conditions during the crisis. This would have avoided the scenario whereby, only this week, most large private hospital groups have announced that their operating theatres may have to close and, outpatient activity will soon be restricted to remote consultations by telephone or video. As a result, patients with time critical conditions may experience a delay in their diagnosis or treatment, with an adverse effect on their outcome or survival.
Patients at risk if diagnosis is missed or delayed
To illustrate how coronavirus is already having an effect on cancer diagnosis and treatment, I will use my own speciality of breast cancer as an example. Many people will not be aware that one of the effects of the COVID-19 outbreak is that NHS outpatient capacity has been drastically reduced and referrals are now being prioritised. As of this week, many NHS trusts have moved to a position where the following patients with breast symptoms will no longer be eligible for the urgent two-week wait pathway and their appointments will be cancelled including women <25 years of age with any symptoms, women <35 years of age with breast pain and men <50 with any breast symptoms. In some instances, diagnostic investigations including breast imaging and biopsy will have to be delayed until those resources are reinstated. In addition, with limited access to fully staffed operating theatres during this crisis, a prioritisation of cases for surgery is now taking place and the Association of Breast Surgery has written guidelines on how best to prioritise or alter breast cancer treatment to cope with reduced access to surgery, chemotherapy or radiotherapy. As a medicolegal expert on delay in diagnosis of breast cancer, I know only too well that delays in breast cancer diagnosis can lead to patients ultimately requiring more treatment and having a worse prognosis and in certain cases, losing their chance of survival. Therefore, the longer that the coronavirus is allowed to reduce access to timely breast cancer diagnosis and treatment, the greater the negative impact on patient outcomes. It is likely that this scenario will be similar for other common cancer types and many other acute healthcare interventions that are currently being rationed or cancelled.
Negative impacts on cancer patients
It is important in times of any crisis to make decisions in a timely manner, and avoid unnecessary delay, but we have to recognise that these decisions need to be continually challenged and reviewed. During the last decade in the UK, best practice diagnostic and treatment pathways have been established for the majority of common cancers with resultant improvements in survival. For example, my own research in Cambridge has previously shown that the use of triple assessment (breast examination, breast imaging +/- biopsy) will make the correct diagnosis in 99.6% of all patients with breast symptoms, and overall 10-year survival is now 80% for all patients with breast cancer. Many cancer specialists are therefore very concerned that cancer diagnosis and cancer treatment are already being negatively impacted by prioritisation of patients for diagnostic investigations and surgery, as well as alterations to routine cancer treatment pathways. Depending on the length of this disruption to routine services, it is possible that delays to accurate diagnosis or best practice treatment could have a detrimental effect on outcomes & survival for cancer patients and we must therefore do all we can to keep pathways open for cancer diagnosis and treatment. Until that happens it is inevitable that cancer specialists will compare the results of healthcare interventions for coronavirus, such as intensive care and mechanical ventilatory support, with their own benchmark outcomes and survival for their own cancer specialty.
Public-private partnership could help to protect cancer patients
By the end of May 2020, I would also like to see a protected network of private hospitals established to manage NHS & private patients with time critical diagnostics and treatment for cancer and other acute healthcare interventions, for new cases as well as the backlog of patients that have built up during the lockdown period. That way, the negative impact of delayed cancer diagnosis and treatment could be minimised for all patients in the UK and, protect the future security of the private healthcare sector. Putting politics to one side, private hospital groups have always been an essential part of the strategy to help support the NHS to reach its waiting time targets but, abandonment of their core insured business could make UK PMI companies look elsewhere for provision of clinical services for their members, and threaten the future security of some private healthcare providers.
Better assessment of outcomes in ICU is vital
The recent report from the intensive care national audit & research centre (ICNARC) has been widely misreported as showing a survival rate of approximately 50% for patients critically ill with coronavirus admitted to intensive care units (ICUs). Closer scrutiny of the data reveals that, out of a total of 775 reported patients, only 165 have left intensive care with a median stay of 4 days and of these, 48% died and 52% were discharged alive. It remains to be seen what the outcome is for the remaining 610 patients who remained in intensive care for longer periods of time and whether their mortality is higher or lower than the “shorter stay” patients. Only then will we know the true survival rate for ICU admission for patients seriously ill with coronavirus infection which at present is at best uncertain. In the meantime, when compared to more than 5000 patients with other types of viral pneumonia treated in ICU from 2017-2019, where 22% of patients with a median ICU stay of 6 days died, the early mortality results from the coronavirus study appear to be significantly higher at 48%.
Until now, the entire government strategy has focused on making sure that there are enough ICU beds at the peak incidence of the disease so, the overall percentage of patients who survive ICU care will have a major impact on future decision making and prioritisation of healthcare resources in the UK and other countries. If the survival of coronavirus patients treated in ICU is much lower than expected when compared to other patients with viral pneumonia, then it may be time to re-deploy resources to protect the treatment of other serious and time critical conditions as I have suggested.
The wider economy is also facing an emergency
The current information from the UK government’s scientific and medical advisors is that the current lockdown is likely to be in place at least until the end of May 2020, and some restrictions may stay in place for a number of additional months. The effect of the lockdown has had a major impact on UK businesses of all sizes, as well as the UK economy, and it is imperative that a clear strategy is developed to get employees back to the workplace safely by switching to a different type of test for COVID-19.
At present, UK testing has focused on taking nasal swabs to detect the presence of the virus in frontline NHS workers so that coronavirus-positive clinical staff can be isolated to stop spread of the infection. In the next few weeks, a new type of test will be able to look for antibodies to the coronavirus in the blood by a simple finger-prick test and, this test will be able to tell if the person tested has ever been exposed to the virus. For those people who have already developed immunity to the virus, they can safely return to work or be released from social distancing to allow a phased easing of the current government restrictions. For those people who have never been exposed to the virus, the restrictions may have to stay in place until the number of new cases per day reaches a pre-defined threshold.
The development of a low-cost yet effective antibody test that can be performed in centralised laboratories on a finger-prick blood sample collected at home, is a fundamental requirement to getting UK employees back to work safely at the end of the lockdown period. While this would be a significant development to making work a safer place for NHS workers and patients, it could also be co-funded by private employers and employees in parallel with NHS testing. Check4Cancer has experience of collecting finger-prick blood tests for cancer screening, and we are keen to work with laboratories that have a validated antibody test to ensure that this test is distributed as widely as possible, on a not-for-profit basis, throughout the UK private workforce through our partnerships and collaboration with insured and corporate sectors, as well as multiple brokers and intermediaries that work with UK PLC. We would also be able to collect information from those tested on their geographic location, as well as whether they had been exposed to the virus or had any symptoms, to help better understand how the virus has spread throughout the UK.
The impact of the coronavirus pandemic, and the UK government’s strategy to deal with it, will have far reaching consequences for all UK citizens, UK PLC and the wider economy. While many companies may better understand the benefits of home working and videoconferencing as a way to avoid unnecessary travel in the future, there may be a negative impact in terms of physical and mental health. We must ensure that the future strategy continues to reflect the expanding body of evidence to mitigate these adverse effects on the health and wellbeing of our population and minimise the negative impact on the long-term outcome of the COVID-19 pandemic.
Professor Gordon Wishart
Chief Medical Officer at Check4Cancer